Provider Demographics
NPI:1336379171
Name:MAYHALL, JACK (LMFT)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:MAYHALL
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9325 WHITE OAK AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-2347
Mailing Address - Country:US
Mailing Address - Phone:310-422-6803
Mailing Address - Fax:
Practice Address - Street 1:9325 WHITE OAK AVE
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-2347
Practice Address - Country:US
Practice Address - Phone:310-422-6803
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-14
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC33009106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist